Incident investigation·October 3, 2023

On 10/03/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced Case Management visit to discuss resident on resident altercations involving R1, specifically LIC 624s dated 07/26/23 and 8/21/23. LPA identified herself, the reason for the visit and asked to speak with the Designated Facility Administrator. LPA proceeded to tour the facility with Carlin Robertson, the Business Office Manager, and Karan Bassi, the Director of Residential Services. LPA observed 18 residents in the Rose Dining Room participating in the Sunshine Club. This LPA also viewed 5 resident rooms where the bedding and mattresses were inspected along with the contents of resident bathrooms. This LPA also observed staff de-escalate 2 distressed residents: the first displayed general anxiety and the second was convinced someone stole her lunch. The LPA reviewed the LIC 602 for R1, and it had not been updated since 03/03/2021. LPA requested R1’s needs and services plan for 07/26/23 as well the plan currently being utilized. In the plan dated 04/28/23, it states that R1 should be getting safety checks 4 times per shift. In the plan dated 8/31/23 it states that R1 should be getting safety checks every hour. With regard to the section titled,” Disposition and Behaviors” there were no changes to the existing plan. It stated, “Occasional intervention to de-escalate” and lists that the resident may be, “Physically disruptive (pushing, biting, throwing, or hitting) and that R1 had a, “History of physical Aggression or violence.” On the final page of the report it scores the needs of the resident by category. For the category Disposition and Behaviors , R1 scored a 6 on the report compiled on 04/2'8/23. After 2 resident on resident altercations, one in which the police were called to the scene, nothing in R1s care plan had changed. LPA requested copies of the EMAR for R1s medications for 07/26/23 as well as what R1 was currently being prescribed. They were almost identical with the only differences being that back in July, R1 was taking more medications for digestive issues and a skin rash. The LPA also reviewed the LIC 602 and it had not been updated since 03/03/2021. Deficiencies were observed and cited during this case management visit and have been cited on the LIC 809 D page. Appeal Rights provided, Exit interview.